the thoughts of a surgeon in the notorious province of mpumalanga, south africa. comments on the private and state sector. but mostly my personal journey through surgery.

Monday, March 10, 2008

resus fun

some time ago i read a post about the worst resus ever. i thought i've seen worse. so here is the first installment in what might be a short series.

i was a junior registrar i was working in kalafong/hell. it was late at night. my house doctor and i were relaxing in the anesthetists' tearoom. we were the only one's there.

suddenly the phone rang. it was a sister in high care.

"hello, can you come and tube a patient?" i had no patients at that time in high care.

"whose patient is it?" i asked.

"the physician's". (small note. in south africa, we call an internist a physician. the word physician is not generally used for doctor. in fact if you were to call a surgeon a physician, he would probably be offended.)

"why doesn't he intubate his own patient?" i asked.

"he is here trying but he needs your help." the picture came into focus. i asked my standard question.

"should i run or can i walk?"

i entered high care out of breath, even though it wasn't all that far from the tearoom, my house doctor in tow. i expected to be given charge, but the physician was at the head of the patient. he immediately told me i was there to support and that he was going to tube. i took in the scenario.

there was a 20something male in clear distress. the physician was holding a mask to his face, making sure he formed an airtight seal between his skin and the mask. only problem.. it was a venturi mask that is not meant to be used in a resus and has large holes on the side. a seal, airtight or otherwise, is useless. also you can't actively pump air into the lungs, so if the patient is in trouble, in trouble he will remain. i took a step back. my house doctor and i exchanged glances.

"amazing!" she remarked. "i can't believe what i am seeing." i wasn't sure what to do. he had told me in no uncertain terms that i was not to take over and yet everything else about what he was doing was uncertain to say the least. to try to somehow get a better understanding of what was happening i tried small talk.

"what's wrong with him?"

"kidney failure and now pulmonary edema."

"he looks pretty pale."

"yes, his hb is 4" (extremely low but probably a chronic state.) "in fact i think i'd better order him some blood. here, hold the mask while i draw some blood." and with that he moved away from the head. this clown was actually going to draw blood while his patient died. before i could say anything i found myself holding the ridiculous mask to the patient's face while the physician moved to the arm and commenced drawing blood. i had two immediate thoughts. the first was that my senior registrar would walk in and see me holding this pathetic mask to a dying patient's face. i would never live that down. neither would the patient.the second was that the physician had relinquished the head. i was in charge! immediately i told the sister to get the ambu mask and bag. (this is the correct mask to actively pump air into the lungs.)

i turned up the oxygen and began pumping. i then got the laryngoscope ready. i injected a bit of dormicum and prepared to tube. as i started to tube, the physician moved back to the head and tried to shift me out of the way. there was no way i was going to let him at the patient again. i tubed while he tried to shoulder me out the way. i just ignored him. i checked the position of the tube, told the physician to start bagging the patient and left.

shocking,but not unusual...i did a resus on a neonate last year, alas, was assigned a student nurse to help me: bad idea. while bagging, i asked for a size 3 et tube and laryngoscope... and was handed a NASOGASTRIC tube! she couldnt understand my agitation: a tube's a tube, right? things went from bad to worse, ending with me losing my temper a little bit, and sadly, a baby dying.

Scary story, but unfortunately not entirely unfamiliar. We had a patient cardiac arrest in our oncology dept, when the ER doctor arrived the nurse handed the IV cannula to her thinking she'd prefer to insert it. She nearly ripped it back out of the Doc's hand when the woman asked for some local anaesthetic!!

Further to the issue of physicians. here on the west side of Oz, a physician is usually a specialist eg cardiac, respiratory, etc. They are generally medically inclined, for complex patients, surgeons will usually share patient management with physicians. GPs are the family doctors.

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disclaimer

the aim of this blog is to give insight into the mind of a particular surgeon, me. although every story is loosely based on fact, patients have been changed suitably to protect their identity. the opinions expressed are mine alone and are not meant to be considered medical advice or the opinion of any institution.